This Maine Medicaid (MaineCare) rule implements requirements from a federal settlement agreement governing children's behavioral health services. It establishes a Single Assessment process to determine eligibility and appropriate level of care for Medium and High Intensity Behavioral Health Services, sets timely service delivery obligations for community providers, requires contingency plans for staff backup, and limits the Department's ability to deny services based on complexity of need. The rule applies to all MaineCare providers serving children under 21 with behavioral health disabilities, including mental health, substance use, and developmental disabilities.
View official sourceTABLE OF CONTENTS PAGE 7.01 INTRODUCTION1 7.02 DEFINITIONS1 7.02-1 Authorized Entity1 7.03-2 Child or Children1 7.02-3 Community Provider1 7.02-4 Emergency Department Stay1 7.02-5 Medium and High Intensity Behavioral Health Services 1 7.02-6 Out-of-Home Placement1 7.03 SINGLE ASSESSMENT2 7.03-1 Purpose and Overview2 7.03-2 Providers Required to Refer to the Single Assessment3 7.04 TIMELY SERVICE DELIVERY4 7.05 CONTINGENCY PLANS5 7.06 COMPETENCY AND TRAINING5 7.07 Multiple Providers Serving One Member5 7.08 LIMITS ON DENYING BEHAVIORAL HEALTH SERVICES5 7.09 TELEHEALTH6 7.10 DATA REPORTING6 7.11 COMPLIANCE WITH CHAPTER I, SECTION 1, REQUIREMENTS6 7.12 REIMBURSEMENT6 7.01 INTRODUCTION This rule implements several requirements in accordance with the settlement agreement between the United States of America and the State of Maine (U.S. District Court, District of Maine, Case 1:24-cv-00315-SDN), effective December 20, 2024 (the “Agreement”). This rule is intended to describe processes available to, and requirements for services delivered to, Children who have both a behavioral health disability and behavioral health needs. Behavioral health disabilities include mental health diagnoses, substance use disorders, and developmental disabilities. Behavioral health needs are addressed through behavioral health services, consistent with the Agreement. In the event of a conflict between a requirement of this rule and any provision of the MaineCare Benefits Manual (MBM) other than Ch. I, Sec. 1, or any of the rules listed in Section 7.03-2(D), the terms of this rule supersede the conflicting provision and shall apply. 7.02 DEFINITIONS 7.02-1 Authorized Entity is an organization, entity, or individual authorized by the Department of Health and Human Services (Department) to perform specified functions pursuant to a signed contract or other approved signed agreement. 7.02-2 Child or Children are MaineCare members who are under twenty-one (21) years of age. 7.02-3 Community Provider is a behavioral health service, case management, or care coordination provider who, through an agency or on an individual basis, provides community-based services to individuals under the age of twenty-one (21). 7.02-4 Emergency Department Stay occurs when a Child: (A) enters an emergency department primarily because of a behavioral health need related to a mental health or developmental disability, and (B) remains unnecessarily in an emergency department because of such a behavioral health need. A stay is “unnecessary” when the stay extends because of the Child’s unmet behavioral health need. 7.02-5 Medium and High Intensity Behavioral Health Services include all services covered in Section 28; intensive outpatient program services, children’s assertive community treatment, children’s home and community based treatment, multisystemic therapy, and functional family therapy covered in Section 65; high fidelity wraparound services covered in Section 92; children’s residential care facility (CRCF) services in Section 97; therapeutic foster care and therapeutic intensive home services in Section 98; and psychiatric residential treatment facility (PRTF) services in Section 107. 7.02-6 Out-of-Home Placement is a residential setting other than a family home where a Child receives services primarily to address a mental health or developmental disability. Out-of-Home Placements include, but are not limited to, CRCFs, PRTFs, hospitals, and psychiatric hospitals. Emergency departments, therapeutic foster care homes, and therapeutic intensive homes are not Out-of-Home Placements. 7.03 SINGLE ASSESSMENT 7.03-1 Purpose and Overview The Department or its Authorized Entity shall complete the Single Assessment described below for all Medium and High Intensity Behavioral Health Services. The Single Assessment determines the clinically appropriate level of care needed to meet a Child’s behavioral health needs and determines eligibility for Medium and High Intensity Behavioral Health Services. Absent emergency or other exigent circumstances, or school-related Section 28 services, the Single Assessment will be the only assessment used to determine eligibility for Medium and High Intensity Behavioral Health Services. A Child does not need a Single Assessment in order to access school-related Section 28 services, when those services are both delivered by a School and prescribed on an individualized education program (IEP) or individualized family service plan (IFSP). The Department or its Authorized Entity will accept referrals for the Single Assessment which are made through a Department-approved referral form from healthcare providers, school staff, and responsible state employees. Parents and families may ask any healthcare provider, school staff, or responsible state employees to refer a Child for a Single Assessment. Children may self-direct themselves to a Single Assessment, meaning a Child does not need a case manager or care coordinator to undergo the Single Assessment. The Department or its Authorized Entity will support Children who do not have a case manager or care coordinator through all aspects of the Single Assessment. When a Child does not have a case manager or care coordinator at the time of the Single Assessment, the Department or its Authorized Entity will also determine whether a Child is eligible for targeted case management under MBM Section 13 and children’s standard behavioral health home services under MBM Section 92. Children can be reassessed through the Single Assessment at any time at the request of the Child, their family, or care coordinator, and if the Child, family or care coordinator disagrees with the outcome of the Single Assessment, they may request a review of the determination. The Single Assessment consists of the following components: A. The age-appropriate Level of Care Utilization System suite of instruments: Early Childhood Service Intensity Instrument (ECSII) for ages zero (0) to five (5); the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) for ages six (6) to eighteen (18); or Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) for ages eighteen (18) through twenty (20); and B. Review of the Child’s diagnosis(es) and former treatment records; C. An interview with the Child and the Child’s parents, guardian, and, when feasible, natural supports, former providers, and/or educators; and D. As needed to determine eligibility for Medium and High Intensity Behavioral Health Services, a diagnostic evaluation and/or functional assessment. Explanation of Services. Following the Single Assessment, the Department or its Authorized Entity will coordinate with the Child, family, and case manager or care coordinator if the Child has one to review and explain the nature of the services for which the Child is eligible, the settings in which those services are delivered, and the benefits of receiving services in the home or community. The Department or its Authorized Entity will also address any concerns or objections the Child or the Child’s family has about receiving services in the home and community. The Child and family may then, during the meeting or at a later date as part of service planning, make informed choices regarding the Child’s service(s). Referral for Services and Prior Authorization. After the Child and family select service(s) the Child has been found eligible for, the Child’s case manager or care coordinator, if the Child has one, will refer the Child to provider(s) of the Child and family’s choice that deliver the chosen service(s). If the Child does not have a case manager or care coordinator, the Department or its Authorized Entity will refer the Child to provider(s) of the Child and family’s choice that deliver the chosen service(s). No referral need be made if the Department or its Authorized Entity has already approved a current prior authorization for the chosen provider(s) to deliver the chosen service(s) to the Child, or if the Child otherwise needs no referral to receive the chosen service(s) from the chosen provider(s). The Department or its Authorized Entity will approve prior authorizations for any service a Child is found eligible for following the Single Assessment. 7.03-2 Providers Required to Refer to the Single Assessment Except for those providers listed in Section 7.03-2(D), all MaineCare providers must offer to any Child and, if appropriate, to the Child’s parents or guardian, to refer the Child to a Single Assessment if: A Child’s parent or guardian requests assistance to address the Child’s behavioral health need that Medium or High Intensity Behavioral Health Services can reasonably be expected to meet; A Child’s parent or guardian requests assistance to place the Child in an Out-of-Home Placement; The provider believes, based on their experience and professional judgment, that the Child should be placed in an Out-of-Home Placement; or The provider becomes aware that a Child has been arrested and referred to the Department of Corrections pursuant to 15 M.R.S. § 3203-A. Hospitals and psychiatric hospitals delivering services under Sections 45 and 46, respectively, must offer to any Child and, if appropriate, the Child’s parent or guardian, to refer the Child to a Single Assessment if the Child has an Emergency Department Stay or is admitted for inpatient psychiatric care to address a mental health or developmental disability. C. All MaineCare providers, except for the providers explicitly excluded in subpart D, who become aware that a Child is having or has had an Emergency Department Stay or is admitted for inpatient psychiatric care and determines that the Child has not yet been referred for a Single Assessment by the hospital must offer to refer the Child to the Single Assessment. D. Excluded Providers. Providers that deliver services under the following Sections of the MaineCare Benefits Manual (MBM) are not required under this Section 7.03-2, but may at their discretion offer to refer Children to the Single Assessment: Section 2, Adult Family Care Services Section 7, Free-standing Dialysis Services; Section 15, Chiropractic Services; Sections 18, 19, 20, 21, and 29, HCBS waiver services; Section 25, Dental Services and Reimbursement; Section 43, Hospice Services; Section 55, Laboratory Services; Section 60, Medical Supplies and Durable Medical Equipment; Section 71, National Diabetes Prevention Program Services; Section 75, Vision Services; Section 80, Pharmacy Services; Section 95, Podiatric Services; Section 101, Medical Imaging Services; and Section 113, Non-Emergency Transportation Services. E. Providers who offer to refer a Child to the Single Assessment must document in the Child’s record that they made the offer and whether the Child or Child’s parent or guardian accepted or declined the offer. 7.04 TIMELY SERVICE DELIVERY Community Providers must, to the greatest degree possible considering certain workforce, financial, or other systemic constraints that may be outside their control, minimize undue delays in delivering services and make services available in time to prevent Children from unnecessarily entering or remaining in an Out-of-Home Placement or having an Emergency Department Stay. For purposes of timeliness, a Child unnecessarily enters or remains in an Out-of-Home Placement when the Child is eligible for Medium and High Intensity Behavioral Health Services, is awaiting the start of such services, and a delay in the start of such services is the primary reason the Child enters or remains in an Out-of-Home Placement. 7.05 CONTINGENCY PLANS Community Providers must develop, adopt, and comply with a contingency plan that details the measures the provider will take so that Children have access to back-up staff when regularly scheduled staff are unavailable. Contingency plans may include, but are not limited to, the names or positions of backup providers, dates or days of the week when the backup providers will be available, which backup providers are qualified to deliver which service, and a family communication plan on how to inform families when their normal providers are out and when and how they will receive scheduled services. Upon a provider’s request, the Department will support providers in developing contingency plans. Providers must share contingency plans with the Child and the Child’s family and care coordinator or case manager, if any. Case managers or care coordinators must ensure the Child’s individualized service plan incorporates the contingency plans of any Community Provider serving the Child. For purposes of this rule, “individualized service plan” has the same meaning as in the Agreement. 7.06 COMPETENCY AND TRAINING Behavioral health service and care coordination providers must have competency and the appropriate training in the services they deliver. Specific training requirements for covered services are included in the applicable Sections of the MBM. 7.07 Multiple Providers Serving One Member If one (1) Community Provider cannot fully meet a Child’s needs, the Department, to the greatest extent allowed by state and federal law, will authorize multiple Community Providers to deliver medically necessary services to the Child. 7.08 LIMITS ON DENYING BEHAVIORAL HEALTH SERVICES The Department or its Authorized Entity will not deny behavioral health services for Children due to: Complex behavioral health needs; Significant physical or medical needs in addition to behavioral health needs; or The need for behavioral health services for up to twenty-four (24) hours per day. 7.09 TELEHEALTH Providers may deliver services via telehealth to the extent permitted by, and in accordance with, Chapter I, Section 4, Telehealth Services, and any telehealth-related requirements in applicable Sections of the MBM. 7.10 DATA REPORTING Upon request and within timeframes established by the Department, providers must submit to the Department any and all data and information related to provision of services that the Department deems necessary for the Department to demonstrate compliance with the Agreement. 7.11 COMPLIANCE WITH CHAPTER I, SECTION 1, REQUIREMENTS Providers must comply with all applicable requirements in the MBM, Chapter I, Section 1, including but not limited to making their premises available for announced and unannounced visits by the Department and providing the Department full access to inspect, review, and audit all medical, quality assurance, financial, administrative, and other relevant records and documentation for any and all purposes related to administration of MaineCare. 7.12 REIMBURSEMENT Reimbursement provisions for the services that are the subject of this rule are set forth in the Sections in the MBM applicable to such services. RULEMAKING HISTORY: STATUTORY AUTHORITY: 22 M.R.S. Section 42 Emergency Rule: January 30, 2026, Filing 2026-030 APAO ACCESSIBILITY CHECK (Word): April 9, 2026 EFFECTIVE (NEW, NON-EMERGENCY): April 14, 2026 – filing 2026-087